Nursing Elites

1. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

• A. Perform Kegel exercises daily
• B. Perform light exercise for 3 hours each day
• C. Avoid bathing for 3 days
• D. Avoid sitting in a chair for more than 2 hours

Correct answer: A

Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.

2. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

3. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

• A. WBC count.
• B. Serum potassium.
• C. Hemoglobin level.
• D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

4. What are the key nursing considerations for a patient with a central venous catheter?

• A. Maintain sterility during dressing changes
• B. Change the dressing weekly
• C. Monitor blood pressure and fluid balance
• D. Monitor the catheter site for infection

Correct answer: A

Rationale: The correct answer is A: Maintain sterility during dressing changes. It is crucial to maintain sterility during dressing changes for patients with central venous catheters to prevent infections. Changing the dressing weekly (Choice B) is not frequent enough to prevent infections effectively. Monitoring blood pressure and fluid balance (Choice C) is important for overall patient care but not specific to central venous catheter management. While monitoring the catheter site for infection (Choice D) is important, the key consideration is to prevent infections through proper sterile techniques during dressing changes.

5. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

• A. Irrigate the wound with normal saline.
• B. Apply a wet-to-dry gauze dressing.
• C. Use a cotton ball to cleanse the wound.
• D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

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